SLR - February 2020 - John P. Carolin

Strategies for Reconstruction of the Plantar Surface of the Foot: A Systematic Review of the Literature

Reference: Crowe, Christopher S. M.D.; Cho, Daniel Y. M.D., Ph.D.; Kneib, Cameron J. B.S.; Morrison, Shane D. M.D., M.S.; Friedrich, Jeffrey B. M.D.; Keys, Kari A. M.D, Strategies for Reconstruction of the Plantar Surface of the Foot: A Systematic Review of the Literature, Plastic and Reconstructive Surgery, 2019 Apr; 143(4), 1223-1244

Scientific Literature Review

Reviewed By: John P. Carolin, DPM
Residency Program: West Penn Hospital – Pittsburgh PA

Podiatric Relevance: The plantar foot is a challenging area to cover in both traumatic and chronic conditions. This area is challenging both due to the large pressure demands of the plantar surface of the foot and the availability of local tissue for coverage in some cases. The aim of this paper was to review different techniques for various types of plantar foot defects. A systematic review was performed to identify studies describing techniques, relevant modifications, and outcomes for reconstruction of the plantar surface.

Methods: A systematic literature search was performed to identify articles relating to reconstruction of the plantar skin and soft tissue. Databases used for this query included PubMed, Embase, and Scopus. 1624 articles were identified and of these a total of 280 unique articles were included for analysis. In all, these articles encompassed 2684 reconstruction cases.

Results: Several different techniques were utilized by the various physicians in the articles reviewed. Techniques ranged across the spectrum of the reconstructed ladder; including skin grafting (10 percent), local/regional flaps (53 percent), free tissue flaps (32 percent), with the remaining articles describing multiple other reconstructive methods. Heel defects were most frequently associated with free tissue flaps. Additionally, multiple local/regional flaps were described with the most commonly utilized being the reverse sural artery flap. Hindfoot deficits were the most frequently reconstructed while midfoot deficits only accounted for 4 percent of reconstructions. Protective sensation remained intact in most of both the free flap and local flap techniques regardless of primary neurotization. Neurofasciocutaneous flaps demonstrated improved two point discrimination. Intrinsic muscle flaps of the foot are not routinely performed due to concerns of postoperative gait abnormalities and availability of other options.

Conclusions:  Given the wide variety of different surgical techniques utilized in these articles, this paper elucidates multiple modalities at the surgeon’s disposal to assist in healing difficult plantar wounds. There is no single method which was shown to definitively treat the variety of all plantar defects.  Complications varied wildly depending on the paper reviewed, even for identical flap types; however, the rate of flap loss was similar to flap utilization in other parts of the body. This article services as an excellent reference for the various options of these challenging defects from small defects that can be treated with a toe fillet flap to large deficits requiring a latissimus dorsi flap. The algorithm provided, is a good starting point for surgical decision making; however, final decision is patient dependent and should be based on overall presentation of patient and surgeon comfort level and experience.  

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